|Year : 2017 | Volume
| Issue : 1 | Page : 61-65
Noncompliance in psychosis
Siddharth Kalucha, KK Mishra, Sachin Ratan Gedam
Department of Psychiatry, JNMC, DMIMS (DU), Wardha, Maharashtra, India
|Date of Web Publication||25-Jul-2017|
Department of Psychiatry, JNMC, DMIMS (DU), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Compliance broadly means the degree to which a person's behaviour, is constant with taking the drugs prescribed, life style changes advised, keeping with appointment date. Psychosis by its very nature impairs patient's judgement and insight so it's very natural that chances of non-compliance in psychosis is high. Jim Rosack explained the phenomenon of adherence to medication in terms of refill rate. Aim and Objective: The study was aimed at assessing reasons for drug non-compliance among patients receiving neuroleptic medications. Objective to study socio-demographics variables of these non-compliant psychiatric patients. Material and Method: 180 consecutive non-compliant psychotic patients were interviewed using ROMI scale and soico-demographic proforma. Results: Most common reason for drug non-compliance was denial of illness, financial obstacles, side effects of medications, stigma of mental illness among others as accessed by ROMI scale. Age at onset of mental illness was significantly associated with mean scores for non-compliance of ROMI scale. Conclusion: psychosis has high chances of drug non-compliance. These are patient related, illness related and doctor related. This issues like denial of illness or financial obstacles need to be dealt with judiciously to improve compliance and quality of life.
Keywords: Denial of illness, noncompliance, psychosis, stigma
|How to cite this article:|
Kalucha S, Mishra K K, Gedam SR. Noncompliance in psychosis. J Datta Meghe Inst Med Sci Univ 2017;12:61-5
| Introduction|| |
Compliance broadly means the degree to which a person's behavior is constant with taking the drugs prescribed, lifestyle changes advised, and keeping with appointment date. Drug noncompliance with medical conditions requiring long-term medications such as rheumatic fever and glaucoma have varied from 15% to 80%. Hence, it is not at all surprising that drug noncompliance in psychiatric patients is even on higher sides, especially when these patients are treated on outpatient department. It can be as high as 50% as reported by study conducted by Lipman et al. Psychosis by its very nature impairs patient's judgment and insight so it is very natural that chances of noncompliance in psychosis are high. Noncompliance for the medication is pivotal area of concern in psychosis as it contributes to relapse and repeated admissions in hospitalization of the patients due to illness exacerbations. In other words, patients who do not follow the schedule of treatment or the medication prescribed to them can be labeled as nonadherent. Nonadherence is a serious problem in both developed and developing countries. It applies across all age groups and to all patients seen in hospitals, both chronic and acute. When it comes to psychiatry, it becomes all the more important as psychiatric illness, which generally by its nature impairs insight and judgment, especially psychotic illness which places psychiatry patients more at risk of deviating from prescribed forms of drug treatment thus making them medication noncompliant. Jim Rosack explained the phenomenon of adherence to medication in terms of refill rate. Refill rate is the proportion of days of proper adherence to prescribed medication by the patient calculated in relation to the total number of days advised. Patient who had only 50% of their expected refill rate were termed “nonadherent.” Those who filled prescription between 50% and 80% of the expected refill rate were termed partially adherent. Those who filled between 80% and 110% were termed “adherent.” Those who filled their prescription at more than 110% of expected rate were termed “excess fillers.” The current study was done to find the reasons for noncompliance in population catering to low socioeconomic status using rating of medication influences (ROMI) scale.
The study was aimed at assessing reasons for drug noncompliance among patients receiving neuroleptic medications.
The objective of this study was to study sociodemographic variables of these noncompliant psychiatric patients.
| Materials and Methods|| |
The study was conducted in psychiatry outpatient of a tertiary care hospital in central India. The study was a cross-sectional hospital-based study. One hundred and eighty consecutive psychotic patients between 18 and 65 years of age of either sex, having symptoms/illness exacerbation due to drug noncompliance, were taken into the study after fulfilling the inclusion and exclusion criteria. Diagnosis was made according to the International Classification of Diseases by consultant and included diagnostic categories were schizophrenia, acute and transient psychotic disorder, schizoaffective disorder, bipolar disorder, severe depressive disorder with psychotic symptoms, persistent delusional disorders, and psychosis not otherwise specified (NOS). All the patients must be receiving antipsychotic medications for at least 1 year or more. Patients were classified as noncompliant according to Jim Rosack criteria. These patients were interviewed. The sociodemographic profile of these patients was recorded using semistructured pro forma. ROMI scale was then administered on the patient to know subjective reason for noncompliance. ROMI is a reliable and valid instrument and can be used to evaluate patient's subjective reasons for medication noncompliance. This method has a sensitivity of 55% but a specificity of 88%.
- Patients who had illness exacerbation due to drug noncompliance who were taking neuroleptic medications
- Patients between 18 and 65 years of age
- Patients of either sex
- Patients who are able to give informed written consent
- Patients who were on regular medications for at least 1 year.
- Patients who were acutely psychotic and were not fit to answer questions
- Patients who are having associated severe physical problems
- Patients having substance dependence as primary diagnosis or using psychoactive substance
- Patients who were not able to give a written informed consent.
Tools to be used
- Semistructured pro forma for sociodemographic data
- ROMI scale in schizophrenia
- Jim Rosack criteria to identify patients as noncompliant.
| Results and Discussion|| |
The most frequent reason given by patients for noncompliance was denial of illness (46.67%). The second reason given for noncompliance was financial obstacles (18.89%), followed by (third most frequent) stigma or embarrassment of illness or over taking medications (13.33%), followed by (fourth most common) no perceived daily benefit (12.78%), followed by (fifth most common) distressed by side effects of medications (11.11%), followed by (sixth most common) access to treatment problems (7.78%), followed by (seventh most frequent) negative relation with clinician (2.22%), followed in last (eighth most frequent) by family/friends opposed to medications (1.11%). None of the patients in the current study reported negative relation with therapist, practitioner opposed to medications, substance abuse, and desire to be hospitalized again as a strong reason for drug noncompliance [Table 1].
The most frequent reason for noncompliance was denial of illness (46.67%). The finding of our study is in accordance with the study done by Lacro et al. in 2002, who also concluded that the noncompliance in patients receiving neuroleptic medications was denial of illness.
Financial obstacles as a reason for noncompliance were seen in 18.89% of patients. This may be due to the fact that as the present study was carried out rural population belonging to low socioeconomic status. Findings of the present study are consistent with the study done by Perkins in 2002, where authors stated that high cost of treatment is a common factor for drug noncompliance in patients receiving antipsychotic medications. Stigma, embarrassment due to mental illness or taking medications, was seen among 13.33% of our study sample. Our findings are consistent with the study carried out by Hudson et al. in 2004, where it was found that the most common reported factor for noncompliance was related to the stigma of taking medications. No perceived daily benefit leading to drug noncompliance in the present study was seen among 12.78% in our study sample. In study done by Liu-Seifert et al. in 2005, similar finding was observed by author, that is, poor control of psychotic symptoms along with worsening of symptoms was reason for discontinuing the medications which as the patients did not perceive daily benefits of neuroleptic medications. Distress caused by side effects of medications was reason for drug noncompliance in 11.11% of patients in our study group. Similar findings have been noted in study done by Liu-Seifert et al. in 2005, where noncompliance was significantly associated with patient experiencing distressing side effects of neuroleptic medications. Reason for noncompliance in the present study due to access to treatment problems was seen in 7.78% of patients. Similar findings have been observed in study done by Chandra et al. Negative relationship with the treating clinician (psychiatrist) as a reason for drug noncompliance was seen in 2.22% among our study group. Similar findings have been observed in study conducted by Rungruangsiripan et al. Reason given for drug noncompliance in 1.11% of patients was due to opposition by family/friends toward continuing the antipsychotic medications. Similar findings have been found in the study done by Shoib et al. where author stated that because of others suggestions (friends and family), patient preferred to go to faith healers instead of taking prescribed drugs thus leading to noncompliance. In the current study, none of the participant gave reason of desire to be hospitalized again and again as a reason for drug noncompliance. Findings of our study are in accordance with study conducted by Ansari and Mulla in 2014 where authors used ROMI scale to access reasons for noncompliance. In the current study, substance abuse/use by patients was an exclusion criteria. Hence, it is natural that no patient gave the reason that substance use was responsible for noncompliance in that patient. Similar findings are also noted in study done by Shoib et al. in the year 2003, where substance abuse was not a reason for drug noncompliance in any of the patient in spite of substance abuse being not an exclusion criteria in their study.
In the present study, majority of the sample consisted of patients with schizophrenia that is 46.70%. 15.60% of patients were diagnosed as having acute and transient psychotic disorder. 12.80% of patients had diagnosis of bipolar affective disorder. 7.80% of patients had diagnosis of severe depressive disorder with psychotic symptoms. 6.70% of patients had diagnosis of persistent delusional disorder. 5.60% of patients were diagnosed with schizoaffective disorder and 5% of patients were diagnosed with psychosis NOS [Table 2].
In the current study, psychiatric diagnosis was not significantly associated with noncompliance. However, majority of our noncomplaint patients had diagnosis of schizophrenia, i.e. 46.70%. In a study done by Sultan et al. in 2014, authors stated that most common psychiatric diagnosis in which noncompliance is observed was schizophrenia (45.16%).,
Out of 180 total patients, 20% were between age groups 18 and 25 years. There was almost equal distribution of gender among sample size of 180 patients. 50.60% patients were males and 49.90% were females. Majority of patients among our sample were married (63.30%) and unmarried (28.30%), 5% were widow, 3.33% were divorced. None of the subjects included in the present study were educated above 12th standard. Majority of patients (53.90%) were working and 46.10% of patients were not working. Fifty-five percent of patients in the current study were financially independent while rest of 45% of patients were dependent on someone else financially. In majority of patients (47.80%), caregiver did not supervise medications but in rest of sample size, that is, 42.80% caregiver did supervise the medications.
[Table 3] shows that age, gender, marital status, education status, marital status, financial status, whether the caregiver supervises the medication or not, duration of mental illness, and psychiatric diagnosis are not statistically significant with mean ROMI scale.
|Table 3: Association of variables with mean rating of medication influences scale|
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Only age at onset of illness is statistically significant with mean ROMI score for noncompliance. It means that the lesser the age at the onset of illness, more are chances of noncompliance. Similar findings are observed in study conducted by Hui et al. in 2005, where authors found that noncompliance is higher in younger patients having earlier age of onset of psychotic symptoms.
Strength and limitations
This study was done in population of rural India catering to population belonging to low socioeconomic strata. This study highlights the important reasons for drug noncompliance in these patients.
- As this was a hospital-based study, it has its own limitation because it is not the true representation of the community
- Since it measured only subjective reasons of drug noncompliance, subjectivity will always remain an issue
- Past history of noncompliance was not assessed.
We took consecutive 180 noncompliant psychotic patients. Jim Rosarch criteria were used to identify them as noncompliant. ROMI scale and sociodemographic pro forma were then applied to these patients. Main reason for noncompliance was denial of illness, no perceived daily benefit, financial obstacles, distressed by side effects of medications, and stigma of mental illness. It was found that sociodemographic variables such as age of onset of illness, age of noncompliant patient, gender, marital status, financial status, and employment status were not statistically significant with mean ROMI scale. Only age at onset of illness was statistically significant with mean ROMI scale.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]